summary Nail Bed Injuries are the result of direct trauma to the fingertip and can be characterized into subungual hematoma, nail bed laceration, or nail bed avulsion. Diagnosis is made by careful inspection of the nail bed integrity. Treatment depends on severity and degree of nail bed injury but generally requires removal of the nail and nail bed repair. Epidemiology Incidence nail bed injuries are included under the umbrella of fingertip injuries finger tip injuries are the most common hand injuries seen in the hospital emergency department Demographics 3:1 male-to-female predominance Etiology Pathophysiology mechanisms of injury include crushing fingertip between two objects catching finger in a closing door saw injury snowblower injury direct blow from a hammer Associated conditions DIP fractures or dislocations Anatomy Nailbed and surrounding tissue perionychium nail nailbed surrounding skin paronychium lateral nail folds hyponychium skin distal distal and palmar to the nail eponychium dorsal nail fold proximal to nail fold lunula white part of the proximal nail matrix sterile login to view 3 more bullets germinal login to view 4 more bullets Presentation Symptoms pain Physical exam examine for subungual hematoma inspect nail integrity Imaging Radiographs recommended AP, lateral and oblique of finger login to view 1 more bullet Subungual Hematoma Most commonly caused by a crushing-type injury causes bleeding beneath nail Treatment drainage of hematoma by perforation indications login to view 1 more bullet techniques login to view 2 more bullets nail removal, D&I, nail bed repair indications login to view 1 more bullet technique login to view 1 more bullet Nail Bed Lacerations Laceration of the nail and underlying nail bed usually present with the nail intact and a subungual hematoma greater than 50% of nail surface area Treatment nail removal with D&I, nail bed repair indications login to view 1 more bullet modalities login to view 1 more bullet Avulsion Injuries Avulsion of nail and portion of underlying nail bed Mechanism usually caused by higher energy injuries Associated conditions commonly associated with other injuries including distal phalanx fracture login to view 1 more bullet Treatment nail removal, nail bed repair, +/- fx fixation indications login to view 1 more bullet technique login to view 2 more bullets nail removal, nail bed repair, split thickness graft vs. nail matrix transfer, +/- fx fixation indications login to view 1 more bullet technique login to view 3 more bullets Techniques Nail bed repair nail removal soak nail in Betadine while repairing nail bed nail bed repair repair nail bed with 6-0 or smaller absorbable suture RCT has demonstrated quicker repair time using 2-octylcyanoacrylate (Dermabond) instead of suture with comparable cosmetic and functional results splint eponychial fold splint eponychial fold with original nail, aluminum, or non-adherent gauze Complications Hook nail caused by advancement of the matrix to obtain coverage without adequate bony support Treatment login to view 1 more bullet Split nail caused by scarring of the matrix following injury to nail bed Treatment login to view 2 more bullets Prognosis Early treatment of acute injuries results in the best outcomes with minimal morbidity